- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $147.91 / $338.84
| Professional | | $125.89 | $147.91 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $128.82 / $208.93
| Professional | | $128.82 | $128.82 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $128.82 / $128.82 / $162.18
| Facility | 26 | $128.82 | $128.82 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $190.55 / $269.15
| Professional | | $112.20 | $190.55 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $229.09 / $588.84
| Professional | | $229.09 | $229.09 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $128.82 / $128.82 / $162.18
| Facility | 26 | $128.82 | $128.82 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $208.93 / $269.15
| Professional | | $141.25 | $208.93 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $123.03 / $239.88
| Professional | | $117.49 | $123.03 | $239.88 |